Improving safety and embracing change
As always, there a few thoughts “Rattling Around my Brain” (Jackson Browne). I will attempt to join some of the dots.
- I’ve been reading an investment magazine and one of the article titles is “From Science Fiction to Virtual Reality.” (1) The authors comment that, “given the current speed of change it is difficult to envisage what the world will look like in 10 years.” They then reflect on the development of Artificial Intelligence and how with current technology, 45% of work activities could potentially be automated in 10 years. There are a multitude of other examples, such as driverless cars etc.
- Further to the technological theme, I also read a paper reflecting on how the electronic record (EMR) is becoming a standard of care. (2)
- These two papers follow hard on the heels of a recent HDC case of drug error and the adverse comment the Commissioner made about the use of the EMR device that was present. I have discussed these comments with experienced and wise anaesthesiologists, both in NZ and overseas, and non-anaesthetic colleagues, so have heard different opinions and perspectives.
- A very respected colleague suggested I reflect on the human factors and consequences of the above issues using the Process Communication Model (PCM), which many anaesthesiologists are familiar with. (3) It looks at individual personality structures and comprises of six types of personality: http://processcommodel.com/types-of-personality/
In light of the above, I have indulged in some future gazing. Accepting that we are human and will continue to make errors, if we are serious about making our practice safer we will need to change how we do things and adopt some of the above technologies. The obvious topical example is drug error. The Canadian paper looks at the ideal attributes of an EMR. These are:
- Data collection: From a research perspective, the EMR offers significant opportunities for data analyses.
- Decision support and crisis management.
- Error prevention: The paper refers primarily to errors of omission and inaccurate recording. It does not mention incorrect drug errors but could have as this technology is available. I understand that one of the objections to the NZ version of an EMR is the intrusive voice broadcasting the drugs given to the entire theatre. Dr Lara Hopley spoke to this at the recent NZSA “Behind the Scenes Forum.” A possible solution is to have a blue tooth ear piece. Another objection is that currently drug ampoules do not come with a barcode, but this also is changing.
So, there will be changes and change is uncomfortable and even threatening with significant implications for future practice. From a PCM perspective, what drives us and how do we respond to stress? Many of us are either persisters or thinkers and I quote some of the characteristics:
- Thinkers: To feel good and be efficient, you need to be recognised for your thoughts and accomplishments. “Good work.” “Great idea.” Under light distress, in interactions with others, you may want to demonstrate you are doing things perfectly and you may reverse delegate. If distress increases, you could become over controlling, attack others, and argue about time, money, order, or cleanliness.
- Persisters: To feel good and be efficient, you require your convictions/beliefs to be recognised: “I admire you.” “I value your opinion.” Under light distress, interacting with others, you may focus on what is wrong rather than what is right; then, if distress increases, you may push beliefs, be overly suspicious and righteous.
As a group, we tend to NOT be naturally good communicators, especially when time, information and case load pressured. Therefore, we need to consider ways to understand ourselves and our own needs better and through processes such as PCM become better communicators. In addition, we need to take on board comments made by patients in HDC reports, study the recommendations made by external agencies such as the HDC, and use these as a guide to where our practice sits in relation to community expectations. In parallel, we need to be aware that as a group we respond poorly in an emotional and self-esteem sense. Bottom line, we need to be aware of our own, and our colleagues’ mental and emotional health.
As an aside, I have looked at the history of the HDC which has given me a different perspective and deeper understanding of the HDC’s decision making. So, history: I believe that the HDC concept and process is unique to New Zealand and is in part related to the ACC and its implications. This is a complicated topic and goes back to the late 1950s with various modifications through to the 1990s. It illustrates how switched on and progressive our forebears were. The sentinel event was the formation of the Woodhouse Commission resulting in the Woodhouse Report (1967), which eventually led to the ACC Act (1974); ACC’s main purpose was to enable quick treatment and compensation but it also meant that health consumers were no longer able to sue providers. As an unwanted spin-off, substandard healthcare providers were difficult to penalise. Following the 1988 cervical cancer inquiry report, Judge Cartwright realised the need for an independent complaints resolution and educational body. The Health and Disability Act was introduced in 1990 by Helen Clark and led to the formation of the HDC. Its brief was “promoting and protecting the rights of health and disability services consumers, and facilitating the fair, simple, speedy, and efficient resolution of complaints.” This is based on the 10 Rights which became known as “The Code.”
In summary, the Code is about rights to information, dignity, privacy, quality treatment, and lastly but most relevantly – to complain. The Commissioner also has a responsibility to report findings, to educate and to uphold standards. I think without doubt this function has been beneficial for New Zealand health delivery. So, the HDC is very much about consumer advocacy, rather than the provider. I quote: “A provider is not in breach of this Code if the provider has taken reasonable actions in the circumstances to give effect to the rights, and comply with the duties, in this Code.”
The onus is on the provider to prove it took reasonable actions.
For the purposes of this clause, “the circumstances” means all the relevant circumstances, including the consumer’s clinical circumstances and the provider’s resource constraints.”
As providers, we don’t often appreciate this perspective. With this in mind, I find myself increasingly sympathetic with the Commissioner’s findings. This is unfortunate as it puts me at odds with some friends and colleagues – not a good place to be for the Thinker, Persister or even Harmoniser. Unfortunately, in my current role as President I don’t have the luxury of not having an opinion or being able to “fence sit.” However, in conjunction with the technological changes mentioned earlier in this blog, I find myself wondering if the recent HDC case will be a catalyst for change.
May the force be with us all.
- Craigs Investment Partners, News and Views August 2017, pp.12-15
- Tanoubi I, The electronic medical record in anesthesiology: a standard of quality healthcare and patient safety:Can J Anesth/J Can Anesth (2017) 64:693–697